Michael Koumjian, a heart surgeon for nearly three decades, said he considered treating the sickest patients a badge of honor. The San Diego doctor was frequently called upon to operate on those who had multiple illnesses or who’d undergone CPR before arriving at the hospital.

Recently, however, Koumjian received some unwelcome recognition: He was identified in a public database of California heart surgeons as one of seven with a higher-than-average death rate for patients who underwent a common bypass procedure.

“If you are willing to give people a shot and their only chance is surgery, then you are going to have more deaths and be criticized,” said Koumjian, whose risk-adjusted death rate was 7.5 per 100 surgeries in 2014-15. “The surgeons that worry about their stats just don’t take those cases.”

Now, Koumjian said he is reconsidering taking such complicated cases because he can’t afford to continue being labeled a “bad surgeon.

California is one of a handful of states — including New York, Pennsylvania and New Jersey — that publicly reports surgeons’ names and risk-adjusted death rates on a procedure known as the “isolated coronary artery bypass graft.” The practice is controversial: Proponents argue transparency improves quality and informs consumers. Critics say it deters surgeons from accepting complex cases and can unfairly tarnish doctors’ records.

“This is a hotly debated issue,” said Ralph Brindis, a cardiologist and professor at UC-San Francisco who chairs the advisory panel for the state report. “But to me, the pros of public reporting outweigh the negatives. I think consumers deserve to have a right to that information.”

Prompted by a state law, the Office of Statewide Health Planning and Development began issuing the reports in 2003 and produces them every two years. Outcomes from the bypass procedure had long been used as one of several measures of hospital quality. But that marked the first time physician names were attached — and the bypass is still the only procedure for which such physician-specific reports are released publicly in California.

California’s law was sponsored by consumer advocates, who argued that publicly listing the names of outlier surgeons in New York had appeared to bring about a significant drop in death rates from the bypass procedure. State officials say it has worked here as well: The rate declined from 2.91 to 1.97 deaths per 100 surgeries from 2003 to 2014.

“Providing the results back to the surgeons, facilities and the public overall results in higher quality performance for everybody,” said Holly Hoegh, manager of the clinical data unit at the state’s health planning and development office.

Since the state began issuing the reports, the number of surgeons with significantly higher death rates than the state average has ranged from six to 12, and none has made the list twice. The most recent report, released in May, is based on surgeries performed in 2013 and 2014.

In this year’s report, the seven surgeons with above-average death rates — out of 271 surgeons listed — include several veterans in the field. Among them were Daniel Pellegrini, chief of inpatient quality at Kaiser Permanente San Francisco and John M. Robertson, director of thoracic and cardiovascular surgery at Providence Saint John’s Health Center in Santa Monica. Most defended their records, arguing that some of the deaths shouldn’t have been counted or that the death rates didn’t represent the totality of their careers. (Kaiser Health News, which produces California Healthline, is not affiliated with Kaiser Permanente.)

“For the lion’s share of my career, my numbers were good and I’m very proud of them,” said Pellegrini. “I don’t think this is reflective of my work overall. I do think that’s reflective that I was willing to take on tough cases.”

During the two years covered in the report, Pellegrini performed 69 surgeries and four patients died. That brought his risk-adjusted rate to 11.48 deaths per 100, above the state average of 2.13 per 100 in that period.

Pellegrini said he supports public reporting, but he argues the calculations don’t fully take the varying complexity of the cases into account and that a couple of bad outcomes can skew the rates.

Robertson said in a written statement that he had three very “complex and challenging” cases involving patients who came to the hospital with “extraordinary complications and additional unrelated conditions.” They were among five deaths out of 71 patients during the reporting period, giving him an adjusted rate of 9.75 per 100 surgeries.

“While I appreciate independent oversight, it’s important for consumers to realize that two years of data do not illustrate overall results,” Robertson said. “Every single patient is different.”

The rates are calculated based on a nationally recognized method that includes deaths occurring during hospitalization, regardless of how long the stay, or anytime within 30 days after the surgery, regardless of the venue. All licensed hospitals must report the data to the state.

State officials said that providing surgeons’ names can help consumers make choices about who they want to operate on them, assuming it’s not an emergency.

“It is important for patients to be involved in their own health care, and we are trying to work more and more on getting this information in an easy-to-use format for the man on the street,” said Hoegh, of the state’s health planning and development office.

No minimum number of surgeries is needed to calculate a rate, but the results must be statistically significant and are risk-adjusted to account for varying levels of illness or frailty among patients, Hoegh said.

She acknowledged that “a risk model can never capture all the risk” and said her office is always trying to improve its approach.

Surgeons sometimes file appeals — arguing, for example, that the risk was improperly calculated or that the death was unrelated to the surgery. The appeals can result in adjustments to a rate, Hoegh said.

Despite the controversy it generates, the public reporting is supported by the California Society of Thoracic Surgeons, the professional association representing the surgeons. No one wants to be on the list, but “transparency is always a good thing,” said Junaid Khan, president of the society and director of cardiovascular surgery at Alta Bates Summit Medical Center in the Bay Area.

“The purpose of the list is not to be punitive,” said Khan. “It’s not to embarrass anybody. It is to help improve quality.”

Khan added that he believes outcomes of other heart procedures, such as angioplasty, should also be publicly reported.

Consumers Union, which sponsored the bill that led to the cardiac surgeon reports, supports expanding doctor-specific reporting to include a variety of other procedures — for example, birth outcomes, which could be valuable for expectant parents as they look for a doctor.

“Consumers are really hungry for physician-specific information,” said Betsy Imholz, the advocacy group’s special projects director. And, she added, “care that people receive actually improves once the data is made public.”

But efforts to expand reporting by name are likely to hit opposition. Officials in Massachusetts, who had been reporting bypass outcomes for individual doctors, stopped doing it in 2013. Surgeons supported reporting to improve outcomes but were concerned about doctors being singled out for worse rates when they were just taking on difficult cases, said Daniel Engelman, president of the Massachusetts Society of Thoracic Surgeons.

“Cardiac surgeons said, ‘Enough is enough. We can’t risk being in the papers as outliers,’” Engelman said.

Engelman said the surgeons cited research from New York showing that public reporting may have led surgeons to turn away high-risk patients. Hoegh said research has not uncovered any such evidence in California.

Faraci, 75, said his rate (8.34 per 100) was based on four deaths out of 33 surgeries, not enough to calculate death rates, he said. Faraci, who is semi-retired, said he wasn’t too worried about the rating, though. “I have been in practice for over 30 years and I have never been published as a below-average surgeon before,” he said.

Odeh, 45, performed 10 surgeries and had two deaths while at Presbyterian Intercommunity Hospital in Whittier, resulting in a mortality rate of 26.17 per 100. “It was my first job out of residency, and I didn’t have much guidance,” Odeh said. “That’s a recipe for disaster.”

Odeh said those two years don’t reflect his skills as a surgeon, adding that he has done hundreds of surgeries since then without incident.

Marmureanu, who operates at several Los Angeles-area hospitals, had a mortality rate of 18.04 based on three deaths among 22 cases. “I do the most complicated cases in town,” he said, adding that one of the patients died later after being hit by a car.

“Hospital patients don’t care” about the report. he said. “Nobody pays attention to this data other than journalists.”

A man showing early signs of a heart attack — detected by a bot tracking his heart activity from a sensor on his wrist — is picked up by a self-driving car that checks his vital signs on the way to the hospital. There, his doctors video-conference with a specialist, who assesses his symptoms through a Skype-like screen and recommends a treatment plan.

The scenario, inconceivable a generation ago, is closer than you might think. Technological advancements are ushering in a new era of health care, eroding the long-held model of hospitals and doctors’ offices as the physical center of the health system. The change is unfolding on many fronts, and experts say we are on the cusp of a revolution that could come within the next decade.

The growth of telemedicine (video chats with your doctor) and tools to track chronic diseases (wearable glucose-monitoring devices for diabetics) is inching us toward a time when medical care and diagnoses can be accessed from afar, and often without having to see a physician in person.

The explosion of relatively inexpensive direct-to-consumer genetic tests is allowing millions of people to learn potentially life-changing medical information about themselves without ever stepping foot in a doctor’s office.

And cutting-edge research in gene therapy is opening the door to the possibility of people with genetic diseases being treated much earlier in life, and being “cured” for longer periods of time — potentially improving the quality of life for millions.

This rapidly changing landscape raises the question: Will there come a day when we won’t need to go to the doctor’s office anymore? Will we be able to navigate the health system without coming into contact with a medical professional? And would that be good or bad?

Developers of self-driving cars are already considering including some basic inward-facing sensors that can be used for medical applications — such as those that can measure temperature or cameras that can visually assess the health of a passenger — to aid the elderly and people with disabilities, according to Nidhi Kalra, senior information scientist at the think tank Rand Corp. who researches autonomous car policy.

Some people “may have health complaints or challenges that the car needs to be aware of as it’s taking them to the mall,” she said.

Kaiser Permanente, one of the largest health systems in Northern California, recently set up a futuristic mock exam room where patients can sit in front of a computer screen to talk to a doctor remotely while using a stethoscope, digital thermometer and otoscope to check their own symptoms under the guidance of the physician. Kaiser CEO Bernard Tyson has personally participated in the experiment.

“That is the future — being able to provide a great health care service without someone having to get up and go all the way across town for that kind of medical visit,” Tyson said. “All these things represent the moving away from the hospital being the centerpiece of health care.”

Last year, 70 million interactions between Kaiser patients and their primary care doctor were done by secure email, video conference and other remote tools.

Worldwide revenue for telehealth devices and services is expected to hit $4.5 billion next year, compared to $441 million in 2013, according to the business analytics firm IHS Technology. During the same period, the number of people using telehealth services each year is projected to grow from 350,000 to 7 million.

“I don’t think we’ll get to a point where we’ll never see a doctor, but a large percentage (of doctors) will be seeing patients remotely” in the future, said Dr. David Tong, director of the telestroke program at California Pacific Medical Center in San Francisco. His program connects his vascular neurology practice with 20 other hospitals from the Oregon border to Visalia, so hospital physicians can seek his help in treating a stroke patient. Tong does a visual assessment of the patients using technology similar to Skype.

Tong has led the program since its inception a decade ago, when just two hospitals were in the telestroke network, and the concept of talking to a doctor through a screen seemed foreign to many patients. Today, it’s commonplace — “People think, ‘If I do this all the time with my friends, I’ll do it with my doctors too. What’s the difference?’” Tong said.

Despite the promise of remote medical care, though, many traditional barriers to health care remain. Wealth, geography and access to insurance are privileges that no app or technological advancement can replace.

“The major stumbling block right now is financial,” said Tong. “Right now, most insurance doesn’t pay for telemedicine in a very efficient way. That blocks some people from doing it.”

Medicare and Medi-Cal, for example, limit their reimbursement for telemedicine services to psychiatry and to patients who live in rural areas, Tong said.

There may also be drawbacks to receiving care remotely, which reduces the need for physical interaction. Studies have shown that human touch reduces stress, helps premature babies grow faster and improves the lives of nursing home residents.

But in another promising development, medicine is also moving in the direction of preventing diseases before they even cause any symptoms. Efforts by genetic testing firms to screen large populations — coupled with research in gene therapy and gene editing — will give people more information than ever before on their genetic makeup.

As soon as five years from now, “everyone who wants to be sequenced will have been sequenced,” said Dr. Jill Hagenkord, chief medical officer at Color Genomics, a Burlingame company that sells a $249 test that analyzes 30 genes associated with common hereditary cancers including breast, ovarian and pancreatic cancer. People can buy the test directly from Color or on Amazon, but they must submit their health information and have a physician review it and order the test before Color will analyze the sample.

“Whether that’s newborn screening in the hospital system or in a research setting … sequencing data will just exist,” Hagenkord said.

Color is already taking steps toward population screening, working with 40 large self-insured employers including Visa and Salesforce — which collectively cover tens of thousands of people — that subsidize or pay for the test for employees and spouses.

Using gene testing as a preventive tool “doesn’t take the medical professional out of the equation, but maybe you’ll just have a conversation earlier with your doctor,” about getting a colonoscopy sooner or making choices that may reduce your risk of certain cancers, Hagenkord said.

Meanwhile, researchers are working to bring gene therapy from the clinical trial stage to the real world to treat retinal disease and hemophilia — though treatments are not yet available commercially, said Dr. Chris Haskell, who leads Bayer Corp.’s West Coast Innovation Center. Bayer has a joint venture with CRISPR Therapeutics — which uses the gene-editing tool known as CRISPR — to develop and market therapeutics for blood disorders, blindness and congenital heart disease.

“With gene therapies, the industry is moving ahead very rapidly in clinical development toward bringing these to patients very soon,” Haskell said. “Gene editing is still a number of years away behind gene therapy, but has promise for being able to treat many more diseases.”

Gene editing is considered a subset of gene therapy. Gene therapy consists of adding a “missing” part of a person’s DNA, typically through an injection of an engineered virus that carries the replacement gene. With the blood-clotting disorder hemophilia A, patients are missing a blood-clotting protein called factor VIII. This protein is injected and, over the course of the next several days or weeks, the cells start producing the clotting factor and allow the circulatory system to clot normally.

“The trailblazing is happening with hemophilia because we understand the disease,” Haskell said. “But there’s a huge promise for bringing therapies to patients around the world, especially kids with metabolic disorders who have no good therapy.”

Gene editing makes it possible to modify the genetic code — and the applications seem limitless.

“This opens up a whole new realm of ways to treat diseases in that we can turn things on and off, take things out,” Haskell said. “With gene therapy, we have the hammer. Now we have the whole toolbox. However, we’re still learning how to use all these tools.”

And the workshop for those tools? It will be anywhere but your old, familiar doctor’s office.

If the American Health Care Act ultimately becomes law, states will have the option to once again let insurers on the individual market charge those with preexisting conditions more than healthy people. Among the more contentious pieces of the AHCA, which the House of Representatives passed narrowly on Thursday, is a provision allowing states to request waivers to rules otherwise forbidding higher premiums based on a person’s health status. To get a waiver, states would have to explain how their approach would reduce premium growth and increase enrollment or competition; a late amendment to the bill added $8 billion to help defray higher costs to individuals with health conditions.

I have helped manage one federal and two state “high-risk pools” of the kind that could be re-created under this provision of the AHCA. Before the full implementation of the Affordable Care Act, states had significant discretion over their individual insurance markets, and most allowed plans to place a surcharge on individuals with preexisting conditions. Such “risk rating” was allowed because, before the ACA’s coverage mandate, those who didn’t get health insurance through their employer, Medicare or Medicaid could simply go without until they needed it, with no tax penalty. As a result, those who chose to buy insurance on the individual insurance market were more likely to have preexisting conditions and to incur higher health-care costs.

In 35 states, surcharges were applied to those with health conditions through the mechanism of high-risk pools — or plans that segregated these individuals from the rest of the commercial market. High-risk pools insulated healthier customers from higher costs to encourage people to buy coverage before they needed to use it. With adequate funding and affordable pricing, some state high-risk pools worked well.

I was the executive director — and the first employee — of Maryland’s high-risk pool when it opened in 2003. The state provided $120 million a year in subsidies for the plan, and people were eligible to join if they had been turned away by commercial carriers because of conditions ranging from cancer to hypertension, obesity, depression and even acne. Because commercial insurers denied 14 percent of applicants, Maryland’s pool grew to cover 21,000 enrollees — or approximately 20 percent of the market, a good take-up rate. While premiums were approximately 30 percent above what healthy individuals paid, pool members received more extensive coverage. And lower-income members had access to subsidies — this was well before Obamacare’s became available — that cut their premiums up to half what healthy individuals paid.

Inadequate funding produced different results elsewhere, however. Before Maryland, I helped manage California’s high-risk pool, which received $40 million a year in subsidies from tobacco taxes — one-third of what Maryland provided for a state six times more populous. California’s pool enrollment reached a peak of 21,000 in 1999, but it gradually declined as funding remained stagnant, resulting in a waiting list of up to a year. Premiums were 20 to 37 percent above what healthy individuals paid, with no low-income subsidies. Furthermore, California’s pool capped individual coverage at $75,000 annually — a limit hit by 3 percent of members with catastrophic levels of claims.

Another inadequately funded high-risk pool was actually created under the ACA. Because the Obamacare marketplace took nearly four years to launch, the bill established a temporary federal high-risk pool, which I helped set up. Four months after President Barack Obama signed the bill in 2010, the federal Pre-Existing Condition Insurance Plan began covering individuals who had been rejected by commercial carriers. The plan imposed no premium surcharge and was funded through a one-time, $5 billion appropriation. Enrollment peaked at 115,000 before we had to close it to new enrollees, nine months before the Obamacare exchanges opened, to stay within the $5 billion appropriation.

As these experiences show, funding mattered greatly to whether states took a somewhat benevolent (Maryland) or more neglectful (California) approach to high-risk pools. Is the money in the AHCA sufficient to subsidize premium surcharges for those with health conditions? The answer depends on many factors: How would insurers adjust their premiums in the new market? How would consumers respond to the end of the tax penalty, restructured tax credits and a 30 percent premium penalty on those who don’t maintain coverage? Would the elimination of Medicaid expansion coverage affect demand on commercial markets? How many states would request waivers? How well would programs and subsidies be promoted to those with preexisting health conditions?

The AHCA would also provide $130 billion over 10 years — a significant amount — to stabilize the individual and small-employer insurance markets, and states would be required to add tens of billions for market stabilization in the 2020s. How would those funds be applied? How much difference would they make?

If well-administered, the American Health Care Act could allow premiums to stabilize and help those with health conditions acquire affordable coverage. But if not, uninsured individuals with health conditions could end up longing for the good old days of the ACA.

Health insurers are asking for sharp increases in the cost of their Obamacare plans next year, thanks to instability in the law’s coverage markets that’s been compounded by the Trump administration.

In Maryland, Virginia and Connecticut — the first states to make filings public — premiums for Affordable Care Act plans will rise more than 20 percent on average, according to data compiled by ACASignups.net and Bloomberg. The increases follow years of rising premiums under ex-President Barack Obama.

The increases can be blamed in part on uncertainty among insurers about the strength of the law’s requirement that people carry insurance. The Trump administration has raised doubts about whether it will enforce what is considered by some insurers to be an already insufficient penalty.

“Failure to enforce the individual mandate makes it far more likely that healthier, younger individuals will drop coverage and drive up the cost for everyone,” Chet Burrell, chief executive officer of CareFirst, said in a statement. The insurer is asking for an at least 50 percent increase in premiums in Maryland. Burrell said uncertainty over the mandate played a “significant role” in the insurer’s rate requests.

The Affordable Care Act is at a critical juncture. Republicans and Trump want to repeal much of the law, and say the rising premiums are proof it isn’t working. At the same time, many insurers point to a lack of support for Obamacare’s programs as a reason for the increases, and have asked for help.

Rising Premiums

“It would be good to have some more aggressive stabilization efforts going on,” said Joel Ario, a managing director at Manatt Health who previously worked on the Affordable Care Act at the Department of Health and Human Services. “Uncertainty equals higher premiums.”

Health and Human Services Secretary Tom Price has said the administration will do what it can administratively to “support the reform effort by reviewing and initiating administrative actions to put patients, families and doctors in charge of medical decisions, bring down costs, and increase choices.”

Insurers are quitting Obamacare’s markets because the health law is “fundamentally flawed,” Alleigh Marre, an HHS spokeswoman, said in an emailed statement. “Repealing and replacing Obamacare remains the best option.”

Politics and Policy

There are several other factors to blame for rising premiums, including underlying medical costs.

“We are seeing claims experience that reflects increased medical and prescription drug costs along with higher utilization,” Connecticut Insurance Commissioner Katharine Wade said in a statement.

That’s true in Maryland, too, said Insurance Commissioner Al Redmer. There, carriers are requesting average rate increases from 18 percent to 59 percent. That means in the Baltimore area next year, a 40-year-old could buy a basic “silver” plan for $714.95 a month from CareFirst, or one from Kaiser Permanente for $359.25 with a more limited network of doctors.

Medical Costs

“If carriers in Maryland are losing just on medical claims you can’t point to the current political climate and say, ‘Now things are worse,’” he said.

The rates are preliminary, and regulators often have the power to change them. Most other states will report their rates over the next several months.

CareFirst is a major insurer in Maryland, Virginia and Washington, D.C., and sells coverage under the Blue Cross and Blue Shield brand. The company said its premiums still fall short of covering its customers’ medical costs. It projects its accumulated Obamacare losses from the start of the program through the end of 2017 will reach $600 million.

Trump has cheered on some of Obamacare’s troubles, using them to justify his party’s efforts to repeal the law.

“Insurance companies are fleeing ObamaCare – it is dead. Our healthcare plan will lower premiums & deductibles – and be great healthcare!” Trump tweeted on May 4, the day House Republicans narrowly passed a bill to repeal much of the ACA. While the legislation faces a difficult time in the Senate, the premium increases are likely to remain a part of the debate.

Positive Signs?

It’s too early to say whether the results from the three states are indicative of broader trends. An analysis of Blue Cross and Blue Shield plans by S&P Global Ratings showed that insurers’ results were generally improving and the market stabilizing in the law’s third year.

BlueCross BlueShield of Tennessee will expand in the state next year, entering counties around Knoxville that would otherwise have no Obamacare plans after Humana Inc. said it would exit. After recording more than $400 million in losses from 2014 through 2016, BCBS Tennessee’s financial performance this year is improving, according to a letter the insurer sent to state regulators Tuesday.

Still, its premiums will include additional costs because of “the potential negative effects of federal legislative and/or regulatory changes,” CEO JD Hickey said in the letter. “These risks include but are not limited to the elimination of Cost Sharing Reduction subsidies (CSRs), the removal of the individual mandate and the collection of the health insurer tax.”

Scaling Back

Anthem Inc., which sells insurance under the Blue Cross and Blue Shield brand in 14 states, has said it may scale back that footprint. In Virginia, where it has 165,000 customers in the individual market, Anthem is raising rates about 38 percent. In Connecticut, the insurer has 35,000 customers and is raising rates 34 percent.

“We are forecasting that the individual market will continue to shrink, and that those individuals with greater health-care needs will be the most likely to purchase and retain their coverage,” Anthem told Connecticut regulators.

In some cases, rather than raising rates insurers are dropping out. Humana is withdrawing from Obamacare’s individual market entirely. Aetna Inc. has quit Virginia and Iowa has experienced broad pullouts. In an interview on ABC’s This Week with George Stephanopoulos, House Speaker Paul Ryan said the withdrawals showed the law is failing.

“What we’re trying to do here,” Ryan said, “is step in front of this collapsing law and make sure that we can have a system that works, a system with choice and competition and affordable premiums.”

If it becomes law, the American Health Care Act will have the biggest effects on people who buy their own insurance or get coverage through Medicaid. But it also means changes for the far larger employer health system.

About half of all Americans get health coverage through work. The bill would make it easier for employers to increase the amount that employees could be asked to pay in premiums, or to stop offering coverage entirely. It also has the potential to weaken rules against capping worker’s benefits or limiting how much employees can be asked to pay in deductibles or co-payments.

Whether those changes happen depends on how the Trump administration, states and employers act. The possible effects on the employer health system got little attention during congressional debate.

The employer health benefit system existed long before the Affordable Care Act and was little changed by that law, which focused on expanding coverage for people who did not get their insurance from work. But Obamacare did expand some consumer protections for employer coverage. It also included a controversial “employer mandate,” which required large employers to offer affordable, comprehensive coverage to their workers or face a fine.

The Republican health bill, which passed the House last week and faces changes in the Senate, would weaken or eliminate those protections.

Employers who do not offer insurance to their full-time workers would no longer be fined. Under a Republican health law, benefits consultants predict that most employers would keep offering insurance so as to retain workers. But smaller employers, particularly in certain industries, may choose to cut back.

In its estimate of the effects of an earlier version of the bill, the Congressional Budget Office said that about seven million fewer Americanswould have insurance through work if the Republican health bill became law, compared with what would happen under current law. (Many of those people would still get coverage, the office said — they would just need to buy it themselves — but some would become uninsured.)

Employers would also be freed from penalties if their insurance did not meet a certain affordability standard for their workers; that could mean charging workers a larger share of insurance premiums.

Changes to Obamacare’s consumer protection rules are harder to predict. But it is possible, through the interaction between the health bill and current regulations, that employers would be able to skirt rules that forbid them from limiting the total amount of health care they will pay for in a year or a worker’s lifetime. A rule capping the amount that a worker can be asked to pay in deductibles and co-payments each year could be similarly vulnerable. That possibility was covered last week in The Wall Street Journal.

Matthew Fiedler, a fellow in economic studies at the Brookings Institution and a former Obama administration official, explained in a recent blog posthow the bill could bring back coverage limits. He said that the Trump administration could prevent employers from rolling back the rules through regulation. But he noted that a permissive regulatory approach, which could allow employers to impose limits on coverage, seemed consistent with the administration’s policy preferences. “I think it’s the most likely outcome, but it’s not a guaranteed outcome.”

Zach Hunter, a spokesman for the House Energy and Commerce Committee, which helped draft the bill, said that legislators did not intend for waivers to have any effect on the employer market. “Any ambiguity caused by previous administrations’ guidance from H.H.S. could be resolved by Secretary Price,” he said, referring to Tom Price. Alleigh Marré, a spokeswoman for the Department of Health and Human Services, told The Journal that the department would write regulations in line with the legislation’s intent.

Before the Affordable Care Act, limits on overall coverage were quite common. A Kaiser Family Foundation study found that 59 percent of American workers with employer health plans were covered by plans with a lifetime limit in 2009. A 2009 study from the benefits consulting firm Mercer reached a similar conclusion. It is not clear whether such caps would become as widespread in the future, but, if allowed, may become appealing for some employers looking to reduce costs.

“Lifetime limits affect very few people,” said Larry Levitt, a co-author of the Kaiser study, explaining employers’ thinking. “It allows you to lower your costs without affecting very many people.” But, he noted, such limits can be devastating to those with very costly health conditions.

Obamacare rules limiting the total amount patients with catastrophic illnesses could be asked to pay through deductibles and co-payments may also be weakened by the health bill. Currently, individuals can’t be asked to pay more than $7,150 annually for essential care. The limit for families is $14,300.

A recent survey of 666 employers from the benefits consulting firm Willis Towers Watson found that 15 percent of the employers would consider imposing lifetime coverage limits if it were allowed. The survey did not ask about raising out-of-pocket maximums.

James Gelfand, a senior vice president for the ERISA Industry Committee, a trade group that works with large employers on health benefits, said he thought the return of lifetime limits was extremely unlikely, even if the American Health Care Act became law. He spoke with some members in April about the issue. “That was an eye roll,” he said.

Changes are most likely among employers with fewer workers, or those that tend to pay hourly wages. Those were the types of businesses least likely to offer comprehensive coverage in the years before the Affordable Care Act. The Mercer study found that about 22 percent of wholesale and retail companies offered their workers so-called “mini-med” insurance plans, made illegal by Obamacare, with sharply limited medical benefits.

The Republican bill would not allow employers to charge higher insurance prices to those with pre-existing health conditions. That practice was barred by the Health Insurance Portability and Accountability Act in 1996, and was not changed by the Affordable Care Act. Some people who buy their own insurance might face a return of such health-based pricing under the Republican bill.

The bill would also ease a current pressure on employers to lower the cost of their health plans. Enactment of the so-called Cadillac tax on expensive insurance plans will be postponed until 2026 under the American Health Care Act.

Even if the law changes, coverage by most large employers is likely to remain widespread and robust, particularly if a strong economy prompts them to compete to attract workers. But even in past downturns, health benefits have proved tricky to take away. In the years before the Affordable Care Act, employers had no requirement to offer coverage and few rules about what benefits they should include. Still, in those years, generous employer coverage was the norm for large companies. “It’s not likely they would abandon that approach in a post-A.C.A. environment,” said Tracy Watts, the United States health reform leader at Mercer.

Under the Republican health bill, it’s up to states whether to dismantle key parts of the Affordable Care Act.

Red, or GOP-leaning, states are sure to be interested in rolling back the law’s coverage requirements and freeing insurers to charge people more when they have preexisting conditions.

As strange as it sounds, deep-blue, heavily Democratic states supportive of Obamacare, including California and New York, may be forced to do the same, according to experts, regulators and consumer advocates.

The American Health Care Act, which narrowly passed the House on Thursday and now heads to the Senate, would significantly cut the federal subsidies on which many Americans rely to buy coverage. Unless the legislation fails or changes substantially, many consumers across the country could see the amount they pay every year for premiums increase by thousands of dollars, making coverage effectively unaffordable.

Few, if any, states would be able to fund subsidies on their own. To keep insurers in the market and bring costs down, state leaders might feel compelled to seek exemptions from rules that require health plans to provide 10 “essential health benefits” and prohibit them from charging higher rates for sicker consumers. The new GOP health care bill would allow such waivers.

“With the skimpier subsidies, states are going to be under enormous pressure to apply for these waivers,” said Sabrina Corlette, a research professor at Georgetown University’s Center on Health Insurance Reforms.

These opt-out provisions could accelerate the unraveling of Obamacare, even in places that fully embraced the landmark law.

“Certainly the Californias and New Yorks of the world will do what they can to hold onto the ACA protections. But when confronted with insurer exits and big price hikes, many states with the best of intentions may feel they have little choice but to get a waiver,” Corlette said.

Republican leaders insist the current health law isn’t worth saving because it has left consumers with double-digit rate hikes, onerous deductibles and little or no competition in some states, as insurers exit the marketplaces.

Rep. Kevin Brady (R-Texas), chairman of the House Ways and Means committee, said the GOP health bill grants states the flexibility they need to remove the “crushing mandates” that have led to “Obamacare plans you don’t want and can’t afford.”

Nationally, the average tax credit for enrollees in the online marketplaces would be 41 percent lower under the American Health Care Act by 2022, according to a study by the Kaiser Family Foundation. (Kaiser Health News, which produces California Healthline, is an editorially independent program of the foundation.)

The GOP bill also ends the penalty for not having coverage, which experts say might increase premiums as fewer healthy people sign up, leaving health plans with a higher proportion of sick patients.

All this could put the focus back on which benefits are deemed essential in health insurance — an all-too-familiar battle in statehouses before the ACA set a nationwide standard.

The health law now requires all plans sold on the individual and small-group markets to cover the 10 essential health benefits, including hospitalization, prescription drugs and mental health treatment. It has made coverage more comprehensive and prevented insurers from selling bare-bones plans that had cheaper premiums but often exposed consumers to huge medical bills after they sought care.

California would be loath to cut benefits. If you’re selling a policy to a young adult without maternity care, that’s nuts.

Even in California, a liberal bastion that enthusiastically implemented Obamacare, the law’s supporters are bracing for a fight over the waivers.

“As premiums go higher, it will create pressure on us to undercut the standards we have,” said Beth Capell, a lobbyist for the consumer advocacy group Health Access California.

In California, premiums and out-of-pocket costs would rise by $2,779, on average, under the House bill, according to the analysis by the Center on Budget and Policy Priorities.

“California policymakers will once again hear what we heard year after year before the ACA: ‘Some coverage is better than no coverage. More limited benefits are better than nothing,’” Capell said.

John Baackes, the chief executive of L.A. Care Health Plan, with about 26,000 enrollees in the California exchange, said state leaders would exhaust every other option before slashing coverage.

“California would be loath to cut benefits,” Baackes said. “If you’re selling a policy to a young adult without maternity care, that’s nuts.”

No matter the state, red or blue, experts anticipate vigorous debate over these waivers because consumer protections under Obamacare have become more popular.

Wisconsin Gov. Scott Walker, a Republican, experienced that firsthand last week when he suggested his state may opt out of the ACA’s preexisting condition rules — and then immediately backtracked amid strong opposition.

Michael Miller, director of strategic policy for Community Catalyst, a Boston-based national consumer group, said waiver requests won’t necessarily proceed “quietly even in the red states. … People have heart disease and cancer and asthma in those states, too.”

At a recent town hall, California’s Sen. Dianne Feinstein was unfairly criticized for expressing concern about proposed state legislation to create a “single-payer” health care system for California. Her concerns are well founded. The practical reality is that setting up a single-payer system, especially for just one state, is unworkable.

Under a single-payer system, health care would be financed through taxing people to support a government-run program rather than through having them or their employers pay for private health insurance coverage. Doing that would require a massive tax increase on California families along with huge pay cuts for nurses, doctors and other health care professionals. And, it would spell the end of the employer-sponsored insurance that half the state relies on and values.

Debating the single-payer proposal also divides the state’s health care community at the very moment that it needs to be united in moving toward universal coverage under our existing system. Abandoning the Affordable Care Act, as Senate Bill 562 does, telegraphs to Congress that California was never committed to this law, which makes preserving our shared progress that much more difficult.

California’s current system relies in large part on employer-sponsored insurance, which is still the source of health care coverage for tens of millions of people. That coverage would disappear under SB 562. Instead of receiving coverage financed by their employers, working Californians would see a tax increase of well over $10,000 per year for many middle-income families.

For some Californians, this will be less than they are paying out of pocket for health insurance. For many it would be more. All, however, could see health spending in the state budget swell toward the state’s total health spending of $250 billion per year, crowding out essential investments that are also critical to the health of Californians, such as funding for education and transportation. Spending less would mean cutting the pay of nurses, doctors and other health care professionals by at least 50 percent.

The average salary of a registered nurse in California is $135,000. In equivalent dollars, Canadian nurses under their single-payer system make $65,000 per year. Though some private insurance companies do make profits, more than 90 cents on the dollar goes directly toward health care services and necessary administrative costs. Eliminating private health insurance companies would also undermine California’s innovative and effective integrated delivery systems that are a source of coverage and care.

Californians rightly criticized Congress for racing forward with health reform proposals before evaluating or “scoring” the actual impacts of these proposals. The current single-payer health care bill has not received an evaluation from our Legislative Analyst’s Office. In fact, it does not yet include a mechanism to pay for the program that could even receive a score, though the bill’s sponsors promise one in the coming month.

When the actual score came out for the first version of the American Health Care Act a month ago, it signaled its death knell since it showed that there would be 24 million fewer people insured as a result of the proposal. The last time a fully articulated single-payer bill was scored in California, it showed that even after the massive payroll tax increases proposed, the funding for the law was still $40 billion short, also effectively ending debate on that bill.

California needs to be leading the nation right now on sensible, responsible public policy. The Legislature is doing that right now on issues like transportation and climate change. This is not the time to abandon our critical leadership on moving toward universal, affordable coverage building on the Affordable Care Act.

The American Health Care Act, set for a House vote Thursday, would transform the nation’s health insurance system and create a new slate of winners and losers.

If the bill becomes law, it will repeal and replace large portions of the Affordable Care Act (Obamacare). It will change the rules and subsidies for people who buy their own insurance coverage, and make major cuts to the Medicaid program, which funds care for the poor and disabled.

Any sizable change in our complex health care system leaves some people and businesses better or worse off. For some, insurance will become more affordable — or taxes lower. Others will lose out on financial support or health care coverage. You can see how you might be affected in our summary of winners and losers.

Winners

High income earners: The bill eliminates two taxes on individuals earning more than $200,000 or couples earning more than $250,000: a 0.9 percent increase on the Medicare payroll tax, and a 3.8 percent tax on investment income. It also allows people to save more money in tax-excluded health savings accounts, a change most useful to people with enough money to have savings.

Upper-middle-class people without pre-existing health conditions: The Affordable Care Act cut off subsidies to help people buy their own insurance at an income of around $48,000 for a single person. The American Health Care Act would let people get government subsidies much higher up the income scale — up to about $150,000. But the bill would allow states to waive rules on minimum benefit standards and rules that prevent insurance companies from charging higher prices to customers with pre-existing illnesses. That means, overall, the gap between the tax subsidies and the cost of needed care could widen, even for some people who will get extra financial help.

Young, middle-class people without pre-existing health conditions: The bill would change how insurance companies price their products in a way that would lower prices for young customers. It also gives them a flat subsidy that is, in many cases, higher than what they would receive under Obamacare. There is some variation by region, and people with pre-existing conditions could be charged higher prices in some states.

People who wish to go without insurance: The bill would eliminate the individual mandate, which charges a tax penalty to Americans who can afford insurance but do not obtain it.

People who want less comprehensive health coverage: The bill would allow insurers to offer health plans with higher deductibles and co-payments, a change likely to lower premiums. Customers in states that waive benefit rules may also be able to buy plans not covering as many medical services, like maternity coverage.

Large employers: The bill eliminates Obamacare’s employer mandate, which required large employers to offer affordable coverage to their workers. If the bill becomes law, companies that do not wish to cover their workers will face no penalty. All large employers would freed of the complex reporting necessary to enforce the provision. It also pushes back enactment of a tax on high-cost employer health plans.

Medical device companies, indoor tanning companies and a few other medical industries:The bill rolls back taxes on devices, tanning, prescription drugs and health insurance products. Some of those industries may lose a little as well as benefiting — insurance companies, for example, may have fewer paying customers.

Losers

Poor people: If it becomes law, the bill is likely to result in many states rolling back their expansions of the Medicaid program to cover childless adults without disabilities. The bill would also substantially reduce subsidies available for Americans just over the poverty line, the group that benefited most from Obamacare’s subsidies. Poor Americans would be much more likely to become uninsured under the bill, according to the Congressional Budget Office, and those who retained coverage would pay much more of their limited incomes on premiums and deductibles.

Older Americans, in most states: The same factors that make the bill better for many young Americans make it worse for those who are older. Insurance companies would be allowed to charge a 64-year-old customer five times the price charged to an 18-year-old one, to cite the most extreme example. The changes in the subsidy formula would also require older middle-class Americans to pay a much larger share of their health insurance bill. The Congressional Budget Office estimates that far fewer older Americans would have insurance coverage under this bill than do under the Affordable Care Act.

People with pre-existing health conditions, particularly in some states. The bill would allow states to waive rules on minimum benefit standards and on rules that prohibit insurance companies from charging higher prices to customers with a history of illness. Those changes could make insurance more expensive for people with a history of serious — or even minor — diseases, and could mean their insurance covers fewer medical services. The benefit changes could also affect Medicaid beneficiaries, and they could mean cutbacks on coverage for mental health and drug addiction treatment. States that waive the rule about prices would be required to set up a program for high-risk customers, and would get some federal funding to do so, but the details are unclear.

Hospitals: The Congresional Budget Office estimates that some 24 million fewer peoplewould have health insurance in a decade if an earlier version of the bill became law. Some of those people will still have medical emergencies and require hospital care. Obamacare made substantial cuts in how much Medicare pays hospitals, on the theory that they would make up the difference with more paying customers. The Republican bill would not restore any of the Medicare cuts. Hospitals in poor communities where a lot of people signed up for Medicaid are likely to experience the biggest hit.

President Donald Trump urged Senate Republicans on Sunday to “not let the American people down,” as the contentious debate over overhauling the U.S. health care systems shifts to Congress’ upper chamber, where a vote is potentially weeks, if not months, away.

Some senators have already voiced displeasure with the health care bill that cleared the House last week, with Republicans providing all the “yes” votes in the 217-213 count. They cited concerns about potential higher costs for older people and those with pre-existing conditions, along with cuts to Medicaid.

Sen. Susan Collins of Maine, a moderate Republican whose vote will be critical to getting a bill to Trump’s desk and who voiced similar concerns, said the Senate would not take up the House bill.

“The Senate is starting from scratch. We’re going to draft our bill, and I’m convinced we will take the time to do it right,” she said.

Mick Mulvaney, Trump’s budget director, also said the version that gets to the president will likely differ from the House measure. Such a scenario would then force the House and Senate to work together to forge a compromise bill that both houses can support.

Collins also complained that the House rushed a vote before the Congressional Budget Office could complete its cost-benefit analysis.

Eager to check off a top campaign promise, Trump sought Sunday to pressure Senate Republicans on the issue.

“Republican senators will not let the American people down!” Trump tweeted from his private golf course in central New Jersey, where he has stayed since late Thursday. “ObamaCare premiums and deductibles are way up — it was a lie and it is dead!”

Trump has said the current system is failing as insurers pull out of markets, forcing costs and deductibles to rise.

The White House on Sunday scoffed at Democratic claims that voters will punish the GOP in the 2018 elections for upending former President Barack Obama’s law. “I think that the Republican Party will be rewarded,” said Reince Priebus, Trump’s chief of staff. House Democratic leader Nancy Pelosi of California has threatened that GOP lawmakers will “glow in the dark” over their vote.

The House bill would end the health care law‘s fines on people who don’t buy policies and erase its taxes on health industry businesses and higher earners. It would dilute consumer-friendly insurance coverage requirements, like prohibiting higher premiums for customers with pre-existing medical conditions and watering down the subsidies that help consumers afford health insurance.

Obama defended his signature achievement in Boston Sunday night while accepting the John F. Kennedy Profile in Courage Award.

“I hope that current members of Congress recall that it actually doesn’t take a lot of courage to aid those who are already powerful, already comfortable, already influential,” he said. “But it does require some courage to champion the vulnerable, and the sick and the infirm.”

Major medical and other groups, including the American Medical Association, opposed the House bill. Democrats are also refusing to participate in any effort to dismantle Obama’s law, while some Republican senators — Rob Portman of Ohio, Shelley Moore Capito of West Virginia, Cory Gardner of Colorado and Lisa Murkowski of Alaska — object to cutting Medicaid, the federal-state health care program for the poor and disabled.

The ACA expanded Medicaid with extra payments to 31 states to cover more people. The House bill halts the expansion, in addition to cutting federal spending on the program, which Trump’s health chief argued is flawed and dictates too much from Washington.

Health and Human Services Secretary Tom Price argued that states will get more freedom to experiment with the program and make sure that people who rely on Medicaid get the care and coverage they need.

“There are no cuts to the Medicaid program,” Price insisted Sunday, adding that resources are being doled out to allow states greater flexibility.

Gov. John Kasich of Ohio questioned what would happen to the mentally ill, drug addicts and people with chronic illnesses under the changes proposed for Medicaid.

“They are going to be living in the emergency rooms again,” potentially driving up health care costs, Kasich predicted.

Senate Majority Leader Mitch McConnell, R-Ky., plans to move forward under special procedures that allow legislation to pass with a simple majority vote, instead of the 60 usually required for major bills in the Senate. That means McConnell can afford to lose just two senators; Vice President Mike Pence would vote to break a 50-50 tie in his constitutional role as vice president of the Senate.

House Speaker Paul Ryan, R-Wis., appeared resigned to the legislative reality that the bill he unveiled with great fanfare, after years of Republican pledges to replace what’s become known as “Obamacare,” will be altered as part of a “multistage process.”

“We think we need to do even more support for people who are older and also more support for people with pre-existing conditions,” Ryan acknowledged. “The Senate will complete the job.”

A political group with ties to House Republican leadership, American Action Network, said Sunday it was buying $500,000 in television time to promote the Republican health care bill. The ad will focus on key elements of the American Health Care Act and thank Ryan and fellow Republicans for “keeping their promise” on the health care issue, the group said.

On the other side, a health advocacy group is launching a six-figure advertising campaign this week targeting 24 Republican House members who voted to repeal Barack Obama’s health care law. Save My Care says the campaign will include a mix of TV and digital advertising, costing more than a half million dollars.

Among those being targeted: Tom MacArthur of New Jersey, the moderate Republican who helped revive the bill by authoring an amendment on pre-existing conditions.

Some House lawmakers have been challenged by the public over the House vote.

Conservative Rep. Raul Labrador, R-Idaho, drew boos Friday at a public meeting for his response to a constituent who said the House bill tells people on Medicaid to “accept dying.

Labrador responded: “That line is so indefensible. Nobody dies because they don’t have access to health care.” The comment traveled quickly on social media.

Collins and Ryan appeared on ABC’s “This Week,” Price was on NBC’s “Meet the Press” and on CNN’s “State of the Union” with Kasich, while Mulvaney was interviewed on CBS’ “Face the Nation.” Priebus was on “Fox News Sunday.”

Republican politicians have campaigned on repealing President Barack Obama’s healthcare reforms pretty much since they were enacted in 2010.

Now, with a governing majority, they’ve had to come up with a replacement plan – a task that has proved much more challenging than they may have imagined.

Here’s a look at some key differences between the existing law, informally known as Obamacare, and the American Health Care Act, crafted by the Trump administration and Republican leadership in the House of Representatives.

Individual mandate

Obamacare: All Americans are required to have health insurance or pay a tax penalty.

Republican plan: The mandate is repealed, but individuals who forgo health insurance for more than 63 days must pay a 30% surcharge on their insurance premiums for a year.

Employer mandate

Obamacare: Companies with more than 50 employees are required to offer health insurance or pay a penalty.

Republican plan: Allows states to define what benefits are mandated or opt out of the requirement entirely.

Pre-existing condition coverage

Obamacare: Prohibits insurers from denying coverage or charging more to individuals who have pre-existing medical conditions.

Republican plan: States can let insurers charge as much as they like to sick people. Allocates $8bn to help subsidise those patients.

Medicaid

Obamacare: Expanded Medicaid health insurance for the poor to cover more low-income individuals.

Republican plan: Phases out Medicaid expansion to reduce federal funding on the programme by $880bn over the next decade, and gives states greater flexibility in administering the programme in exchange for fixed federal spending.

Women’s healthcare

Obamacare: Insurance companies prohibited from charging women more than men for the same health plan and must provide core services including maternity care and contraceptives.

Republican plan: Insurance companies still banned from charging women more, but states could allow insurers to drop maternity care and contraceptives from basic benefits. Also bans women from using federal tax credits to buy a plan that covers abortion.

Older Americans

Obamacare: Insurers can charge older Americans no more than three times the cost for younger Americans

Republican plan: Insurers can charge older Americans five times as much as younger Americans. States would also be able to set their own ratio.

Subsidies

Obamacare: Provided refundable tax credits for low-income individuals who purchased their insurance on government-run marketplaces and support for some out-of-pocket medical expenses.

Republican plan: Alters formula for tax credits, which will expand the benefit to more middle-class Americans but probably raise the costs for some elderly and less-affluent individuals.